• The treatment of obesity has had only limited success and attempts at prevention have been a total failure.

• The traditional models for understanding obesity using simple energy balance may be partially responsible for these poor success rates.

• Scientific thinking in this area has evolved from simple physics, to biological and physiological ways of explaining the obesity.

• A new Ideological paradigm is needed to incorporate the influences of biology, the environment and individual behaviour.

• The inclusion of physiological adjustment to changing energy stores in the model is also a key factor in understanding the dynamics of changing body fatness.

• The mediators through which the influences and moderators work are fat intake and fat utilisation in the body.

In spite of the huge personal expenditure on weight control, the burgeoning weight control industry, and the vast media attention given to the problem, it is obvious that all countries in the western world are losing the battle of the bulge. One possible reason for this is that the issue may have been inadequately conceptualized in scientific terms. The failure to even stabilise the growth rate of obesity at the population level has led some health experts to suggest a paradigm shift in thinking about weight control. It has been claimed that all science progresses through ‘paradigm shifts’ in thinking where a paradigm is defined as ‘. . . the collective set of attitudes, values, procedures, techniques etc., that form the generally accepted perspective of a particular discipline at a particular time’. In light of this, it is interesting to consider the evolution of thinking that has occurred in this area and to come up with a possible alternative, more all-encompassing approach on which better program planning—both prevention and treatment—can be based.

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But such a definition isn’t very helpful. Do people who switch to a macrobiotic diet, for example, have an eating disorder? After all, they have changed their eating habits. Moreover, for some people at least, such a diet may provide insufficient amounts of calories, protein, and other nutrients, thus putting their health in jeopardy.

Although there is some overlap between obesity and the other eating disorders, specifically in terms of problems with body image and self-esteem, the causes and treatment of this disorder are sufficiently different to require a separate book of their own. Experts generally consider obesity a physical disorder, not a psychiatric one, although it may have a psychiatric component to it.

The question of what is and what isn’t an eating disorder is a common and sometimes baffling one. There are many areas of confusion and misinformation. In an effort to sort out this confusion, let me try to answer some of the most prevalent questions about eating disorders that I encounter as a physician specializing in the field.

Are eating disorders a recent problem?

No. Ancient Greeks and Romans wrote about abnormal eating patterns. Medical reports from three hundred years ago describe patients with anorexia. Only recently, however, have doctors tried to define these illnesses precisely, in order to better recognize and treat them. Bulimia, in fact, was only identified as a distinct disorder in the mid-1970s, although the problem existed long before then.

Don’t eating disorders affect only rich white people?

No. Patients can be black, Hispanic, Japanese. Many are by no means rich. A small number are male. In one sense, though, anorexia and bulimia are economic in origin. They occur where food is plentiful, as in the industrialized nations of Great Britain, France, the United States, Germany, and Scandinavia. The incidence in Japan, a “Westernized” nation, is increasing. In areas where scarcity of food is a problem, such as parts of Africa, eating disorders are extremely rare.

Are all anorexics and bulimics women?

Most are, but about 5-10 percent of them are male.

Is a man with an eating disorder gay?

Not necessarily. An eating disorder may be just one facet of a complex personality problem. Some men with these disorders struggle with issues of sexual identity, including homosexuality. Others feel pressure because thinness is highly valued in their professions, such as sports, dance, fashion, or entertainment.

Are eating disorders caused by parents?

Family problems can contribute to the onset and severity of an eating disorder. But they don’t cause it.

Aren’t all eating-disordered families alike: upwardly mobile, with dominating mothers, and no independence for the children?

No. Research has shown that children with eating disorders come from many types of families, including healthy, functional families. It is true, however, that after years of struggling, families may begin to develop problems because of the eating disorder.

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Postponing her indulgences in this way helped Verona end her lifelong battle of the bulge and lose 60 unwanted pounds—permanently.

Certainly, she has come a long way since the days when she carta j ried 212 pounds on her 5-foot-5i/2-inch frame. “I was chubby even § I as a child,” she recalls. “My mother put me on my first diet when I was just 4 years old “It was one of many that Verona would try over | the years. “Usually, I’d lose some weight,” she says. “But as soon as I went back to my old eating habits, the pounds returned.”

Then, in 1994, Verona enrolled in Weight Watchers. “I knew other people who had been successful on the program, so I decided to try it for myself,” she explains. She attended weekly meetings, in which she learned all about food choices and portion control. “The program gave me the structure and accountability that I needed to be successful,” she says.

Newly enlightened on the subject of nutrition, Verona realized that her love of certain high-fat foods, especially pizza and steak fries, could jeopardize her weight-loss efforts. She tried hard to stay away from them, but as she recalls, “I let myself say yes way too often.”

So she adjusted her game plan. Instead of forbidding herself her favorite foods, she simply delayed her indulgences. The steak fries are a great example. “The cafeteria served them every 2 weeks,” Verona says. “Instead of saying I couldn’t have them, I’d tell myself, ‘Wait until next time.’ Two weeks later, I’d ask myself if I still wanted them. Sometimes, I did. Other times, I could pass them up.”

The tactic worked so well that Verona applied it to other foods that didn’t fit into her eating plan. “I had to know up front that I could eat the food sometime in the future,” she explains. “The future could be 10 minutes away or 2 weeks away. The important thing was that I was taking time to think before I ate. That made all the difference.”

With practice, Verona found that she could extend her waiting periods even longer. “I went from 10 minutes to tomorrow to a special event next month,” she says. “I could pass up many fattening foods without feeling deprived.”

And it shows. In just 9 months, Verona was 60 pounds lighter. She has maintained her weight at 152 pounds ever since.

“For a woman of my stature, 152 pounds may seem heavy,” she observes. “But most of that weight is muscle because I’ve been doing strength training all along.” In fact, she became so enthusiastic about exercise that she now teaches aerobics classes on the side. “Working out and learning to say’later’ to fattening foods keeps me trim and fit,” she says.

WINNING A C T I O N

Postpone your indulgences. Three cheers to Verona for coming up with a fabulous craving buster. By telling yourself that you can have a “forbidden” food at a later time, you can turn your back on temptation without feeling deprived. And when the appointed hour arrives, you may find that you can pass up the food that, a few minutes, hours, or days ago, you couldn’t live without. If you still want it, go ahead and indulge. At least you’ve thought about it first.

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